AHCCCS Technical Interface Guidelines (TIG)
Provider Interface
Introduction
The APR-DRG Rate file provides APR-DRG Rate related information used to adjudicate encounters
Media
The file name is PROVIDERAPRDRG.txt and is in the \ftp\shareinfo\provider\prod\out\ folder. The APRDRG file runs weekly on Wednesdays.
Testing
APR-DRG Rate file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
Introduction
AHCCCS has contracts and agreements with Managed Care Organizations and other entities (hereafter referred to as Contractors) to deliver medically necessary services to AHCCCS eligible recipients. The AHCCCS Division of Health Care Management (DHCM) is charged with the responsibility of monitoring the provider networks of Contractors to assure that they are adequate and that they meet the minimum contractual requirements. The Provider Affiliation Transmission (PAT) is an integral part of this monitoring process. Every quarter the Contractors are required to submit information about each individual provider within their network as specified in Contract. Each Contractor is responsible for submitting true and valid information. AHCCCS will regularly conduct verification procedures to monitor the accuracy of the data submitted by the Contractor. The Contractor must use the specifications found in the following pages. Although certain fields are not edited prior to acceptance of the PAT, these fields may be reviewed by the DHCM Operations Unit. If the PAT is not submitted timely, accurately and complete, the Contractor may be required to make corrections immediately.
If there are any questions regarding the PAT or its submission, they should be directed to the DHCM Operations Unit, Executive Staff Assistant.
Schedules
Each contractor is required to submit a minimum of four Provider Affiliation Transmissions per contract year, at least one per quarter. The transmissions must be submitted on or before the 15th of the first month in each quarter.
Media
Contractors will use the following production Outside Server Directory to load data: https://sftp.statemedicaid.us/AZ/AAA/PROD/IN/PAMMDDYY.TXT
‘AAA’ is the health plan acronym and ‘MMDDYY’ is the transmission date.
Testing
Provider Affiliation transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
Introduction
AHCCCS has contracts and agreements with Managed Care Organizations (MCO’s) to deliver medically necessary services to AHCCCS eligible recipients. AHCCCS ACOM Policy 315, AHCCCS Payment Reform Initiative, applies to all AHCCCS MCOs. The purpose of this initiative is to encourage MCO activity in the area of quality improvement, particularly those initiatives that are conducive to improved health outcomes and cost savings, and those related to child and adolescent health, by aligning the incentives of the MCO and provider through shared savings payment arrangements.
The AHCCCS Division of Health Care Management (DHCM) is charged with ensuring that MCO Structured payment arrangements are adequate and that they meet the minimum contractual and policy requirements. The Structured Payment Transmission (SPT) is an integral part of this monitoring process. At least annually all MCO’s are required to submit information about all Structured Payment relationships in place for the reporting year. Each MCO is responsible for submitting true and valid information. AHCCCS will routinely conduct verification procedures to monitor the accuracy of the data submitted by the MCO’s.
The MCO’s must use the specifications found in the following pages. All records and fields will be edited prior to acceptance of the SPT. If the SPT is not submitted timely, accurately and complete, the MCO may be required to make corrections immediately.
If there are any questions regarding the SPT or its submission, they should be directed to the DHCM Finance Unit.
Schedules
The file will be extracted on a weekly basis; every Wednesday
Media
MCO’s will use the following production Outside Server Directory to load data: https://sftp.statemedicaid.us/AZ/XXX/PROD/IN/SPMMDDYY-HPID.TXT , XXX’ is the MCO acronym; ‘MMDDYY’ is the transmission date and ‘HPID’ is the Health Plan ID.
Testing
Structured Payment transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
Link to Provider Interface TIG File Layouts.Structured Payment
Introduction
The Provider File-(provider.zip) gives the Contractor information specific to each AHCCCS registered provider. It is to be used to help adjudicate claims such that payment under the AHCCCS contract is made only to actively registered providers, qualified to perform services approved by AHCCCS for that provider on that Date of Service (DOS).
Schedules
The file will be extracted on a weekly basis; every Wednesday
Media
The file is name is Provider.zip and is in the \ftp\shareinfo\provider\prod\out\ folder.
Testing
Provider file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
Introduction
The Provider Profile- (profile.zip) provides Provider related reference table information used to adjudicate encounters. Data in this file is extracted from the AHCCCS PMMIS data tables. The PMMIS data table reference is indicated after each record number in the layout (e.g. RF***) The RF indicates that the data is from a PMMIS Reference table and is followed by the PMMIS table number.
Schedules
The file will be extracted on a weekly basis; every Wednesday
Media
The file is name is Profile.zip and is in the \ftp\shareinfo\provider\prod\out\ folder.
Testing
Provider Profile file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
Introduction
The Provider Profile 2- (profile2.zip) provides Provider related reference table information used to adjudicate encounters. Data in this file is extracted from the AHCCCS PMMIS data tables. The PMMIS data table reference is indicated after each record number in the layout (e.g. RF***) The RF indicates that the data is from a PMMIS Reference table and is followed by the PMMIS table number.
Schedules
The file will be extracted on a weekly basis; every Wednesday
Media
The file is name is Profile02.zip and is in the \ftp\shareinfo\provider\prod\out\ folder.
Testing
Provider Profile 2 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.
Reference Documents (File Layout)
